Ppp pneumoperitoneum
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Transcript of Ppp pneumoperitoneum
DR MAJID MUSHTAQUEMBBS, MS, FICLS, FMASMINIMAL ACCESS SURGEON ; MAMC NEW DELHI
PNEUMOPERITONEUM
Definition :
Pneumoperitoneum
Laparoscopic space
CREATION OF PNEUMOPERITONEUM
Closed veress needle technique
Open technique
Direct trocar insertion
CLOSED VERESS NEEDLE TECHNIQUE
VERESS NEEDLE TECHNIQUE - Palpate Abd , Empty bladder , NG tube - Position of the patient - Site for insertion - Lift the Abd-wall & hold veress like dart - Angle of insertion - Spring test
Veress Needle
Stab incision
Veress needle insertion
CLOSED VERESS NEEDLE TECHNIQUE
CONFIRMATION OF NEEDLE POSITION - Hiss test - Aspiration test - Drop test - Piston test - Percussion test - Readings on the insufflator - Volume test
Aspiration test
CLOSED VERESS NEEDLE TECHNIQUE
ALTERNATE PUNCTURE SITES
- Palmers point - Right subcostal - Right lower quadrant
Palmers point ..
OPEN ACCESS TECHNIQUE
HASSONS TECHNIQUE ( 1971 ) - Hasson canula - Technique
USING UMBLICAL CICATRIX TUBE - MAMC Technique - Moberg et al
Access using umbilical cicatrix tube
Access using umbilical cicatrix tube
IDEAL GAS FOR INSUFFLATION
Limited systemic absorption across peritoneum
Limited systemic effects if absorbed Rapid excretion if absorbed High solubility in blood Should not support combustion Limited effects with intravascular embolism Colorless , inert , non-explosive Ready available , non-expensive , non-toxic
CARBON DIOXIDE [ CO2 ]
ADVANTAGES - Does not support combustion - High solubility - Eliminated by lungs - Low risk of gas embolism - Readily available - Less expensive
CO2
DISADVANTAGES : - Hypercarbia and acidosis - Stored Co2 may take hours to be eliminated - Direct effects of acidosis ( Cardio
depressant ,Pul – HTN , Syst – vasodilatation ) - Sympathetic + ( Tachycardia ; Increase in
CVP , MAP , Pul A pressure & Vas-resistance)
NITROUS OXIDE
ADVANTAGES - Biologically inert / colorless - Highly soluble - Insignificant changes in AB balance - Less pain
DISADVANTAGES - Supports combustion - Hazardous for operating team
HELIUM
ADVANTAGES : - Neither combustible nor supports
combustion - Minimal effect on acid-base balance - Absence of hypercarbia and acidosis DISADVANTAGES : - Risk of venous gas embolism ( less soluble ) - More diffusible ( low density gas ) - Post operative emphysema takes days to get absorbed .
ARGON
ADVANTAGES : - Non- combustible - Chemically nonreactive - Maintains stable AB-balance
DISADVANTAGE : - Cardiac depressant
PHYSIOLOGICAL EFFECTS OF LAPAROSCOPY
PNEUMOPERITONEUM
POSITION OF THE PATIENT
ANAESTHESIA
EFFECTS OF PNEUMOPERITONEUM ON RESPIRATORY SYSTEM :
Increased PaCO2 [ and ѴCo2 ] Splinting of the diaphragm Decreased lung volumes and capacities
( FRC ; TLV ; Compliance ) Increased airway resistance V / Q mismatch --- Co2[ (a – A) D Co2 ] Endobronchial movement of ETT Hypoxia and hypercarbia
EFFECTS OF PNEUMOPERITONEUM ON CARDIOVASCULAR SYSTEM :
Hypercarbia and Sympathetic stimulation. Tachycardia , Arrhythmias , HTN . Decreased cardiac output . Increased CVP [Decreased venous return]. Increased SVR . Humoral factors . Decreased splanchnic blood flow . No change in coronary blood flow .
EFFECTS OF PNEUMOPERITONEUM ON KIDNEYS :
Decreased renal blood flow .
Decreased GFR and urine output.
OTHER EFFECTS OF PNEUMOPERITONEUM
Regurgitation and aspiration .
Hypothermia .
Increased IOP .
Increased ICP .
PHYSIOLOGICAL EFFECTS DUE TO POSITION OF THE PATIENT :
RESPIRATORY SYSTEM :[Trendelenberg position] - Decreased capacities & compliance - ET shift CVS : Trendelenberg position -- - Increased Venous return , CVP , C.O. - Increased IOP and ICP . [ No change in BP due to reflux vasodilatation
and bradycardia . ]
POSITION OF THE PATIENT :
Reverse Trendelenberg ..
- Pooling of blood in peripheral vessels [ Decreased venous return , CO , BP ] - Venous stasis [ DVT and Pul-Emb ]
EFFECTS DUE TO ANAESTHESIA
Local / Regional : No change in PaCo2
- Minute ventilation increased - Absence of ventilatory depressant effect of G.A
G.A with spontaneous breathing : - Increased minute ventilation not sufficient to keep PaCO2 within normal range ( due to ventilatory depressant effect of G.A )
EFFECTS DUE TO ANAESTHESIA
Mechanical ventilation under G.A : - PaCO2 increases , plateaus after 15-20 minutes . - Minute volume to be adjusted on ventilator.
COMPLICATIONS :
TRAUMATIC COMPLICATIONS :
- Bleeding from abdominal wall
- Visceral injury
- Major vascular injury
Injuries caused by the Veress needle ( % of cases )
696,519 cases of abdominopelvic laparoscopic procedures [55 articles ].
Total of 1,575 injuries [ 0.23% ] Major vascular injuries (0.006%) Major injury to hollow viscera ( 0.0025% )
[ Small gut was most common ] Minor injuries to hollow viscera ( 0.0016 )
[ Stomach was most common ]
Incidence of injuries
One large meta-analysis showed an incidence of vascular injury to be 0.44% in the closed cases compared to 0% in the open cases. They found a bowel injury rate of 0.7% to 0.5% respectively as well.
COMPLICATIONS
RESPIRATORY : - Subcutaneous emphysema
- Pneumothorax
- Pneumomediastinum
- Pneumopericardium
Pneumothorax
Causes : - Potential channels may open - Defects in diaphragm - Weak points in aortic/esophageal hiatus - Pleural tear during surgery at GE junction - Rupture of pulmonary bullae
Pneumothorax
C/F : - Sudden/progressive hypoxemia - Increased peak airway pressure - Subcutaneous emphysema - Auscultation - Decreased movement of one hemi diaphragm.
Pneumothorax
Management : - Avoid ICCT - Increase FiO2 (ventilator setting) - Stop NO2 - Reduce IAP - PEEP (if no pulmonary trauma) - Needle drainage ( If spontaneous resolution does not occur after 1 hour of exsufflation ).
COMPLICATIONS:
GAS EMBOLISM :C/F : - Gas lock in vena cava/right atrium - Tachycardia, Hypotension, Hypoxia - Increased CVP, Arrhythmias , ECG changes - Circulatory collapse - B/L Mydriasis - Delayed recovery , coma, fits , paresis ….
Gas embolism
Diagnosis : - Mill wheel murmur - Aspiration of gas through CV catheter - Precordial / Esophageal Doppler - Capnometry [ Biphasic P ET CO2 ]
Gas embolism
Management : - Stop insufflation & release pneumoperito. - Steep head down and L-lateral position - Increase FiO2 and stop NO2 - Hyperventilation - Aspirate gas through CV catheter - CPR
COMPLICATIONS ( Cont..)
CARDIOVASCULAR : - Arrhythmias - Changes in heart rate - Changes in BP - Circulatory collapse
cvs
Prevention/Management : - Treat CVS problems preoperatively - Avoid excessive IAP - Correct hypoxia and hypercarbia - Slow insufflation / exsufflation - Correct hypovolemia - Slow gradual change in position - Avoid halothane - Drugs -- Atropine , Inotropes , Beta blockers, Nitroglycerin .
COMPLICATIONS :
ASPIRATION
HYPOTHERMIA
REFERENCES :
Hasson HM: A modified instrument and method for laparoscopy.Am J Obstet Gynecol 1971;110:886–887.
Art of Laparoscopic Surgery ; Text book and atlas . C.Palanivelu : First edition ; Volume 1 .
Pawanindra L, Sharma R, Chander J, Ramteke VK: A technique for open trocar placement in laparoscopic surgery using the umbilical cicatrix tube. Surg Endosc 2002;16:1366–1370
An open Access technique to create pneumoperitoneum in laparoscopic surgery . A.-c. moberg, u. petersson, A. montgomery ; Scandinavian Journal of Surgery 96: 297–300, 2007.
P . Lal , A .Vindal , R. Sharma , J .Chander , V.K.Ramteke . Safety of open technique for first trocar placement in laparoscopic surgery: a series of 6000 cases. . Surg Endosc . 2011
REFERENCES :
Palmer R. Safety in laparoscopy. J Reprod Med 1974;13:1–5.
Dingfelder JR. Direct laparoscopic trocar insertion without prior
pneumoperitoneum. J Reprod Med 1978;21:45–7.
Munro MG. Laparoscopic access: complications, technologies and
techniques. Curr Opin Obstet Gynecol 2002;14:365–74. George A. Vilos, MD, Artin Ternamian, Jeffrey Dempster, Philippe Y. Laberge
Laparoscopic Entry: A Review of Techniques, Technologies, and Complications SOGC Clinical practice guideline . JOGC , No. 193, May 2007 , Page 433 -447.
Batra MS , Discoll JJ et al . Evanescent NO2 pneumothorax after laparoscopy . Anaesth-Analg 1983 ;62 : 1121-23.
REF….
Shulman D , Aronson AB . Capnography in early diagnosis of Co2 embolism in laparoscopy . Can J Anaest 1984 ; 31 : 455-59.
Joris JL , Noirot DP , Legrand MJ et al . Haemodynamic changes during laparoscopic cholecystectomy . Anaesth Analg 1993 ; 76 : 1067-71 .
Neumann GG , Sidebotham G et al . Laparoscopy explosion hazards with nitrous oxide . Anaesthesiology 1993 ; 78 : 875-79 .
Yacoub OF , Cardona I et al . Co2 embolism during laparoscopy . Anaesthesiology 1982 ; 57 : 533-35 .
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